The role of culture in treatment Flashcards
ISSUE with role of culture in treatment
there are lots of differences between cultures in how symptoms of mental disorders are expereicned, persented and perceived. Its v important to understand the role of culture in treatment, as these cultural diffs may mean that a treatment which works in one country might not work in another.
We also need to be more critical of studies that use a eurocentric perspective, as results ight not applicable to other countries
historically lots of research n therapy from america n other western approaches
globalizatizing world , benefits - travelling to cultures that their problems may not be understand
We need to move beyond assumptions that all cultures same
Theres evidence that treatment might not be effectve for many patients bc the therapist and patient perceive treatment process differently.
E.g, in intercultural (from diff cultures) settings, rate of patient compliance is much lower, probs bc off diffs in cultural expectations of treatment
Expressing symptoms differently (somatization)
Cultures with stereotypes against mental disorders- more reluctant to share how u feel, or know how u feel. Less likely to seek treatment
Internal model of illness
Paitnets beliefs abt treatment are heavily influenced by their beliefs about the disorder itself, by the way the patient internal represents his or her illness
^ AKA the internal model of illnesses
Concept similar to schemas- culturally determined schematic representation of a mental disorder
Naeem
Conducted study which aimed to develop culturally sensitive CBT programme and asses effectiveness in developing world (they used Pakistan)
Interviews were conducted w depressed patients
Ppt were asked for thoughts abt illness, causes and treatments
Asked abt their views on psychotherapy
Interview data collected w field notes from author during his clinical field practice
Used ppt from psychiatric outpatient clinic in pakistan
Interviews conducted in Urdu language and tape recorded. 9 patients participated
Results
4 themes emerged
Perception of depression- pateints mentioned physical symptoms a lot more. Headaches were most common complaint, sadness mentioned but not emphasized. Patients talked abt how thier brain felt “weak”or they had “tension”, but didnt use specific labels. None recognized depression as an illness, but thought their illness was more mental than physical
Model of causes- patients asked about their knowledge of mental illnesses, and they said their probs were due to “tensions and trauma”, “problems w environment”, “thinking too much”. They never mentioned names of mental illness
Modes of referral for help- some patients referred themselves to clinic, but most were referred to by relatives
Knowledge and experience concerning treatment and depression- most thought they could be cured by “good quality meds”. When asked if they saw non medical healers (magicians, religious healers etc) only 1 patient admitted to it. But it might be bc some ppl didnt want to admit they saw these ppl. Pateitns seemed guarded and careful when talkign abt non-medical treatment
Study helped them develop cbt for local use
GOOD
They gained insight into language patients used, e.g “tension”, and could better adapt CBT
Qualitative research method
V useful when v little is known about a population. THey did study on Pakistan.
Only had 9 pateints
Interviews not generalisable
They focused on reinterpretation of certain somatic symptoms such as signs of depression (e.g headaches).
It was important to note when adapting cbt that although “tension” interfered with pateints’ daily activites, none of them stopped doing them. Some ppt reported increased religious activity
Therapists in this culture would have to deal w patients who continued daily routine regardless of mental state. Patients would be looking for meds that helped them quickly and made them be able to perform tasks again
Culturally sensitive treatment
Evidence based treatment- u start w treatment thats been proved effective in clinical trials, e.g CBT
This can then be adapted to diff cultural contexts
E.g superficially (aka top- down adaptations)(changing how u deliver the service, language, hiring bicultural support staff), or
Deep (aka bottom-up) (changing nature of relationship between therapist and client, changing focus of treatment)
Bottom up vs up down adaptation (deep vs surface culture// the iceberg)
Bottom are the most core things
Top has superficial changes
Emic approach to research
Top down approach- western approach to treatment (all evidence saying its effective is from white middle class countries). Going to new culture and tweaking treatment slightly to fit culture
Bottom up - starting new to create new method of treating
Using the Ecological validity framework, which outlines 8 areas for adaptation
Language
Persons (e.g ethnicity of therapist)
Metaphors
Content (e.g cultural knowledge, values, traditions)
Concepts (beliefs abt treatment
Goals (beliefs abt treatment goals)
Method
Context (e.g accounting for acculturation, country of origin)
ecological framework
Not just saying theres a diff in cultures, but provising a solution for it
Some ppl not taking meds bc of believes- how do we have to adapt treatment to address this?
Griner and smith
Metanalysis of 76 studies w total sample of 25k ppt to examine the benefit of culturally adapted treatments
Only used studies that included quantitative adaption of effectiveness of therpay
Most frequent adaption was the inclusion of cultural values in intervention
E.g in treatment programme w kids, they used storytelling w cultural folk heroes
Results
Moderately strong benefit to culturally adapted intervention
Average effect size from pre to post intervention was 0.45
Format of intervention (group or indv) didnt affect results
Treatments for groups w ppt of same race were 4 times more effective than mized race ones (effect size of 0.49 to 0.14)
Acculturation was important:
Older ppt more responsive to culturally adapted treatment, probs bc older ppt less acculturated
If therapist used ppt’s native language, therapy was more effective (effect size 0.49 to effect size 0.21 if in english)
Conclusion
Cultural adaptations carried out for specific sub populations may be more effective than just naking ttreatments more culturally flexible in general
Clearly shows cultuarlly sensitive treatment is effective, especially if it targets specific groups of indviduals based on cultural background
GOOD
Good
Only used studies that included quantitative adaption of effectiveness of therpay. Less bias/ interpretation needed
paid special attention to eliminating publication bias
Published studies compared to unpublished
They found that effect sizes of these 2 groups didnt differ
BAD
They dont know what specific elemtns of treatment are responsible for increasing effectiveness
E.g language of clinician? Nature of patient therapist relationship? Smth else?
Hodges and Oei
Its also important to take into accoutn cutlure aspects of CBT
Some doubt have been raised about how applicable cbt is to collectivist calues, as it might go against colelctivist calues to take ownership for ones mental health in a more one on one convo w a stranger
Hodges and Oei
Explore conceptual compatability between cbt and common values of chinese culture
Many tyical cbt processes (teaching skills, emphasis on homework, rational reanalysis of thoughts ) go well w traditional chinese values (e.g respecting authority, hard work)
So even though this seems to indicate indiviual therapy might not be approrpiate, its actually even ebtter, c theyre more likely to follow what the therapist said to do
BUT< this tyoe of directive therapist client relationship wasnt empahsized in the OG CBT appraoch (ppt menat to take responsibility for theri own ations and not just follow directions)
CBT shouldnt be excelssively diretive, but using some elements, e.g following up on homework, could match w chinese culture
